ALPRAZOLAM 2 mg Tablet

Region	Plans covering	Tiers	Lowest 30-day cost	Restrictions
New Jersey	12 of 12	2–4	$2.00	12 of 12 plans
Pennsylvania and West Virginia	12 of 12	2–4	$2.00	12 of 12 plans
North Carolina	12 of 12	2–4	$2.00	12 of 12 plans
Alabama and Tennessee	12 of 12	2–4	$2.00	12 of 12 plans
Michigan	12 of 12	2–4	$5.00	12 of 12 plans
Illinois	12 of 12	2–4	$1.00	12 of 12 plans
Arkansas	12 of 12	1–4	$0.00	12 of 12 plans
Texas	12 of 12	2–4	$1.00	12 of 12 plans
Kansas	12 of 12	2–4	$0.00	12 of 12 plans
California	12 of 12	2–4	$5.00	12 of 12 plans
Connecticut, Massachusetts, Rhode Island and Vermont	11 of 11	2–4	$2.00	11 of 11 plans
South Carolina	11 of 11	2–4	$2.00	11 of 11 plans
Oklahoma	11 of 11	2–4	$1.00	11 of 11 plans
Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming	11 of 11	2–4	$1.00	11 of 11 plans
New Mexico	11 of 11	2–4	$4.00	11 of 11 plans
New York	10 of 10	2–4	$5.00	10 of 10 plans
Delaware, DC and Maryland	10 of 10	2–4	$2.00	10 of 10 plans
Georgia	10 of 10	2–4	$2.00	10 of 10 plans
Florida	10 of 10	2–4	$3.00	10 of 10 plans
Ohio	10 of 10	2–4	$2.00	10 of 10 plans
Indiana and Kentucky	10 of 10	2–4	$2.00	10 of 10 plans
Wisconsin	10 of 10	2–4	$5.00	10 of 10 plans
Missouri	10 of 10	2–4	$2.00	10 of 10 plans
Mississippi	10 of 10	2–4	$2.00	10 of 10 plans
Louisiana	10 of 10	2–4	$2.00	10 of 10 plans
Colorado	10 of 10	2–4	$2.00	10 of 10 plans
Arizona	10 of 10	2–4	$5.00	10 of 10 plans
Nevada	10 of 10	2–4	$2.00	10 of 10 plans
Oregon and Washington	10 of 10	2–4	$5.00	10 of 10 plans
Idaho and Utah	10 of 10	2–4	$2.00	10 of 10 plans
Maine and New Hampshire	9 of 9	2–4	$7.00	9 of 9 plans
Virginia	9 of 9	2–4	$2.00	9 of 9 plans
Alaska	9 of 9	2–4	$8.00	9 of 9 plans
Hawaii	8 of 8	2–4	$8.00	8 of 8 plans
Puerto Rico	3 of 3	2	$2.00	3 of 3 plans
American Samoa	1 of 1	2	—	1 of 1 plans
Guam	1 of 1	2	—	1 of 1 plans
Northern Mariana Islands	1 of 1	2	—	1 of 1 plans
U.S. Virgin Islands	1 of 1	2	—	1 of 1 plans

New Jersey — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$59.90/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.0942	$1.4115 units	Quantity limit 15 per 30 days
Horizon Medicare Blue Rx Standard (PDP)$72.30/mo premium · $615.00 deductible	2Generic	$3.00	$4.50	$0.1173	$1.7615 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$77.40/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1548	$2.3215 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$109.30/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.0894	$1.3415 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$118.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2727	$4.0915 units	Prior authorization Quantity limit 15 per 30 days
Horizon Medicare Blue Rx Enhanced (PDP)$139.10/mo premium · $200.00 deductible	2Generic	$6.00	$9.00	$0.1173	$1.7615 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$4.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0992	$1.4915 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$35.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$0.0996	$1.4915 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0821	$1.2315 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$111.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0992	$1.4915 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$22.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3250	$4.8815 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$28.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.3250	$4.8815 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Pennsylvania and West Virginia — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$22.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1423	$2.1315 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$43.50/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.1569	$2.3515 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$62.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.0922	$1.3815 units	Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$74.00/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.0977	$1.4715 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2629	$3.9415 units	Prior authorization Quantity limit 15 per 30 days
Blue Rx PDP Complete (PDP)$164.80/mo premium · $200.00 deductible	2Generic	$5.00	$12.50	$0.0807	$12.10150 units	Prior authorization Quantity limit 155 per 31 days
Blue Rx PDP Plus (PDP)$193.20/mo premium · $615.00 deductible	2Generic	25%	25%	$0.0807	$12.10150 units	Prior authorization Quantity limit 155 per 31 days
Humana Basic Rx Plan (PDP)$6.60/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0973	$1.4615 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0987	$1.4815 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$123.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0973	$1.4615 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$8.20/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3937	$5.9115 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3935	$5.9015 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

North Carolina — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$56.90/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1528	$2.2915 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$78.00/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1063	$1.5915 units	Quantity limit 15 per 30 days
Blue Medicare Rx Standard (PDP)$83.90/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1631	$2.4515 units	Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$110.40/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1091	$1.6415 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2607	$3.9115 units	Prior authorization Quantity limit 15 per 30 days
Blue Medicare Rx Enhanced (PDP)$163.20/mo premium · $0.00 deductible	2Generic	$6.00	$18.00	$0.1631	$2.4515 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$6.80/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1019	$1.5315 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$32.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1037	$1.5615 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$90.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0894	$1.3415 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$110.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1019	$1.5315 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3739	$5.6115 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$4.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3737	$5.6115 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Alabama and Tennessee — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$63.20/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1477	$2.2215 units	Prior authorization Quantity limit 15 per 30 days
BlueRx Essential (PDP)$76.20/mo premium · $615.00 deductible	2Generic	$10.00	$20.00	$0.1523	$2.2815 units	Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$77.50/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1061	$1.5915 units	Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$87.20/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1054	$1.5815 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2544	$3.8215 units	Prior authorization Quantity limit 15 per 30 days
BlueRx Enhanced Plus (PDP)$129.50/mo premium · $150.00 deductible	2Generic	$12.00	$24.00	$0.1523	$2.2815 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0966	$1.4515 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$37.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0981	$1.4715 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$97.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0750	$1.1215 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0966	$1.4515 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$3.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3372	$5.0615 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$3.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3367	$5.0515 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Michigan — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$0.0970	$1.4615 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$14.10/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1507	$2.2615 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$50.40/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.0997	$1.5015 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$78.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2611	$3.9215 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0983	$1.4715 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0992	$1.4915 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$78.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0747	$1.1215 units	Prior authorization Quantity limit 15 per 30 days
Prescription Blue Select (PDP)$78.40/mo premium · $615.00 deductible	3Preferred Brand	20%	20%	$0.0553	$0.8315 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$98.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0983	$1.4715 units	Quantity limit 15 per 30 days
Prescription Blue Premium (PDP)$106.70/mo premium · $0.00 deductible	3Preferred Brand	24%	24%	$0.0553	$0.8315 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3370	$5.0615 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3375	$5.0615 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Illinois — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$40.20/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1373	$2.0615 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1118	$1.6815 units	Quantity limit 15 per 30 days
Blue Cross MedicareRx Basic (PDP)$89.70/mo premium · $615.00 deductible	2Generic	$5.00	$15.00	$0.1392	$2.0915 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$103.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2085	$3.1315 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$104.20/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1257	$1.8915 units	Quantity limit 15 per 30 days
Blue Cross MedicareRx Value (PDP)$119.70/mo premium · $615.00 deductible	2Generic	$1.00	$3.00	$0.1372	$2.0615 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1186	$1.7815 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1197	$1.8015 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0751	$1.1315 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$119.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1186	$1.7815 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4942	$7.4115 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4944	$7.4215 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Arkansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
BlueMedicare Premier Rx (PDP)$181.20/mo premium · $0.00 deductible	1Preferred Generic	$0.00	$0.00	$0.1887	$2.8315 units	Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$0.1060	$1.5915 units	Quantity limit 15 per 30 days
BlueMedicare Value Rx (PDP)$52.50/mo premium · $615.00 deductible	2Generic	$5.00	$15.00	$0.1887	$2.8315 units	Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$54.50/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1135	$1.7015 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$65.10/mo premium · $615.00 deductible	2Generic	$7.00	$27.00	$0.1489	$2.2315 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.90/mo premium · $130.00 deductible	2Generic	$10.00	$54.00	$0.2636	$3.9515 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0829	$1.2415 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0850	$1.2815 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$73.50/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0725	$1.0915 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$92.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0829	$1.2415 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.2674	$4.0115 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2682	$4.0215 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Texas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.00/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.0990	$1.4915 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$89.20/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.1443	$2.1615 units	Prior authorization Quantity limit 15 per 30 days
Blue Cross MedicareRx Basic (PDP)$104.70/mo premium · $615.00 deductible	2Generic	$5.00	$15.00	$0.1362	$2.0415 units	Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$111.40/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1022	$1.5315 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2293	$3.4415 units	Prior authorization Quantity limit 15 per 30 days
Blue Cross MedicareRx Value (PDP)$167.40/mo premium · $615.00 deductible	2Generic	$1.00	$3.00	$0.1490	$2.2315 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$22.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1017	$1.5315 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$41.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1002	$1.5015 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$94.80/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0806	$1.2115 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$118.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1002	$1.5015 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4292	$6.4415 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4295	$6.4415 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Kansas — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Essentials (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$0.00	$0.00	$0.1610	$2.4215 units	Quantity limit 15 per 30 days
Blue MedicareRx Value (PDP)$0.70/mo premium · $615.00 deductible	2Generic	$2.00	$6.00	$0.1696	$2.5415 units	Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$6.70/mo premium · $615.00 deductible	2Generic	10%	10%	$0.1234	$1.8515 units	Quantity limit 15 per 30 days
Blue MedicareRx Plus (PDP)$67.40/mo premium · $0.00 deductible	2Generic	$0.00	$0.00	$0.1696	$2.5415 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.40/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.1496	$2.2415 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$147.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2362	$3.5415 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$15.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0973	$1.4615 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$55.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0998	$1.5015 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$88.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0831	$1.2515 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$116.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0973	$1.4615 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4642	$6.9615 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$14.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.4622	$6.9315 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

California — 12 plans, 12 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$0.0964	$1.4515 units	Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$70.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.0924	$1.3915 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$109.40/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.1569	$2.3515 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$165.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2650	$3.9815 units	Prior authorization Quantity limit 15 per 30 days
Blue Shield Rx Enhanced (PDP)$227.80/mo premium · $0.00 deductible	2Generic	$7.00	$14.00	$0.2169	$32.54150 units	Quantity limit 5 per 1 days
SilverScript Choice (PDP)$103.60/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0920	$1.3815 units	Prior authorization Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$104.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.1056	$1.5815 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$132.20/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1049	$1.5715 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$172.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1049	$1.5715 units	Quantity limit 15 per 30 days
Blue Shield Rx Plus (PDP)$199.70/mo premium · $615.00 deductible	3Preferred Brand	19%	19%	$0.2169	$32.54150 units	Quantity limit 5 per 1 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3860	$5.7915 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$6.20/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.3859	$5.7915 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Connecticut, Massachusetts, Rhode Island and Vermont — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue MedicareRx Value Plus (PDP)$20.70/mo premium · $615.00 deductible	2Generic	$3.00	$6.00	$0.1678	$2.5215 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$32.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1540	$2.3115 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1604	$2.4115 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$139.30/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.0996	$1.4915 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$155.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2557	$3.8415 units	Prior authorization Quantity limit 15 per 30 days
Blue MedicareRx Premier (PDP)$238.60/mo premium · $0.00 deductible	2Generic	$7.00	$14.00	$0.1678	$2.5215 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$8.40/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1195	$1.7915 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$73.60/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.1201	$1.8015 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$138.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1195	$1.7915 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$16.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4766	$7.1515 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4764	$7.1515 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

South Carolina — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1012	$1.5215 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$122.10/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.1540	$2.3115 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2604	$3.9115 units	Prior authorization Quantity limit 15 per 30 days
BlueCross Rx Value (PDP)$139.70/mo premium · $615.00 deductible	2Generic	$17.00	$42.50	$0.0682	$1.0215 units	Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$152.50/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1035	$1.5515 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$10.10/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1045	$1.5715 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$65.60/mo premium · $601.00 deductible	3Preferred Brand	19%	14%	$0.1060	$1.5915 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$98.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0971	$1.4615 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$145.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1045	$1.5715 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$4.80/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4062	$6.0915 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$9.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4060	$6.0915 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Oklahoma — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Blue Cross MedicareRx Basic (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$5.00	$15.00	$0.1543	$2.3115 units	Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$65.40/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1207	$1.8115 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.1469	$2.2015 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$121.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2585	$3.8815 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$126.50/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1187	$1.7815 units	Quantity limit 15 per 30 days
Blue Cross MedicareRx Value (PDP)$167.30/mo premium · $615.00 deductible	2Generic	$1.00	$3.00	$0.1823	$2.7315 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0907	$1.3615 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0939	$1.4115 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0907	$1.3615 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3146	$4.7215 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.3146	$4.7215 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$5.30/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.1427	$2.1415 units	Prior authorization Quantity limit 15 per 30 days
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1533	$2.3015 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$66.50/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1060	$1.5915 units	Quantity limit 15 per 30 days
MedicareBlue Rx Standard (PDP)$101.00/mo premium · $615.00 deductible	2Generic	$1.00	$3.00	$0.1762	$2.6415 units	Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$125.90/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1088	$1.6315 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2266	$3.4015 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$4.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0973	$1.4615 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$20.80/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0992	$1.4915 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$103.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0973	$1.4615 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4287	$6.4315 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$12.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4285	$6.4315 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

New Mexico — 11 plans, 11 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$0.1310	$1.9715 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$6.00	$18.00	$0.1431	$2.1515 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$82.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2175	$3.2615 units	Prior authorization Quantity limit 15 per 30 days
Blue Cross MedicareRx Value (PDP)$111.30/mo premium · $615.00 deductible	2Generic	$4.00	$12.00	$0.1570	$2.3515 units	Quantity limit 15 per 30 days
Blue Cross MedicareRx Basic (PDP)$145.40/mo premium · $615.00 deductible	2Generic	$5.00	$15.00	$0.1566	$2.3515 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1152	$1.7315 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$69.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1176	$1.7615 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$75.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1152	$1.7315 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$104.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0862	$1.2915 units	Prior authorization Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4738	$7.1115 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4743	$7.1115 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

New York — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$35.70/mo premium · $615.00 deductible	2Generic	10%	10%	$0.0866	$1.3015 units	Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$91.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.0916	$1.3715 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$105.80/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1535	$2.3015 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$163.70/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2735	$4.1015 units	Prior authorization Quantity limit 15 per 30 days
SilverScript Choice (PDP)$116.00/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0780	$1.1715 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$140.90/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0955	$1.4315 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$158.90/mo premium · $601.00 deductible	3Preferred Brand	17%	12%	$0.0959	$1.4415 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$173.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0955	$1.4315 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$42.40/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2957	$4.4415 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$45.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.2944	$4.4215 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Delaware, DC and Maryland — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$32.60/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.0953	$1.4315 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$37.80/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1461	$2.1915 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$66.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.0934	$1.4015 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$94.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2511	$3.7715 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0965	$1.4515 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$4.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0971	$1.4615 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0731	$1.1015 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0965	$1.4515 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$5.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3502	$5.2515 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.3502	$5.2515 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Georgia — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$71.20/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1053	$1.5815 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.00/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1516	$2.2715 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2578	$3.8715 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$149.30/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1011	$1.5215 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0952	$1.4315 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$36.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0966	$1.4515 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$100.70/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0826	$1.2415 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$129.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0952	$1.4315 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3523	$5.2815 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3530	$5.2915 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Florida — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
BlueMedicare Premier Rx (PDP)$98.60/mo premium · $615.00 deductible	2Generic	$14.00	$42.00	$0.1183	$1.7715 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$98.70/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1469	$2.2015 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$119.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2400	$3.6015 units	Prior authorization Quantity limit 15 per 30 days
BlueMedicare Complete Rx (PDP)$217.00/mo premium · $615.00 deductible	2Generic	$3.00	$9.00	$0.1183	$1.7715 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$25.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1118	$1.6815 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$92.70/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1110	$1.6715 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0821	$1.2315 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$115.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1110	$1.6715 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4122	$6.1815 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4122	$6.1815 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Ohio — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$65.70/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1056	$1.5815 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$73.70/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1536	$2.3015 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$109.50/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1087	$1.6315 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$123.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2499	$3.7515 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1004	$1.5115 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$23.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1019	$1.5315 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$90.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0821	$1.2315 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$117.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1004	$1.5115 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$7.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4376	$6.5615 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$7.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4361	$6.5415 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Indiana and Kentucky — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$29.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1413	$2.1215 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$78.20/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1085	$1.6315 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$90.30/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.1569	$2.3515 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$117.80/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1082	$1.6215 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$127.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2549	$3.8215 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1004	$1.5115 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$9.90/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1019	$1.5315 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$125.30/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1004	$1.5115 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$8.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3941	$5.9115 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$8.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3927	$5.8915 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Wisconsin — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$0.1156	$1.7315 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.1418	$2.1315 units	Prior authorization Quantity limit 15 per 30 days
SilverScript Choice (PDP)$26.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1378	$2.0715 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1141	$1.7115 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$113.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2342	$3.5115 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1098	$1.6515 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1112	$1.6715 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$110.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1098	$1.6515 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.3874	$5.8115 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3878	$5.8215 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Missouri — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1099	$1.6515 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1484	$2.2315 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1117	$1.6815 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2511	$3.7715 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0983	$1.4715 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1008	$1.5115 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0867	$1.3015 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0983	$1.4715 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3720	$5.5815 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	4Non-Preferred Drug	26%	26%	$0.3719	$5.5815 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Mississippi — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$59.70/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1073	$1.6115 units	Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$77.10/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1136	$1.7015 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$84.70/mo premium · $615.00 deductible	2Generic	$6.00	$18.00	$0.1497	$2.2515 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$140.60/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2634	$3.9515 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0868	$1.3015 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$37.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0890	$1.3315 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$89.90/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0868	$1.3015 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$98.30/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0750	$1.1215 units	Prior authorization Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.2591	$3.8915 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.2597	$3.9015 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Louisiana — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$37.00/mo premium · $615.00 deductible	2Generic	$6.00	$18.00	$0.1465	$2.2015 units	Prior authorization Quantity limit 15 per 30 days
SilverScript Choice (PDP)$44.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1154	$1.7315 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$48.40/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1033	$1.5515 units	Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$60.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1078	$1.6215 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2546	$3.8215 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1002	$1.5015 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$19.30/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1017	$1.5315 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$113.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1002	$1.5015 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$5.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3070	$4.6015 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$6.70/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.3070	$4.6015 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Colorado — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$61.70/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1250	$1.8815 units	Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1203	$1.8015 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$125.00/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1475	$2.2115 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$151.90/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2252	$3.3815 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0971	$1.4615 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$48.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0993	$1.4915 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$105.10/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0776	$1.1615 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$137.10/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0971	$1.4615 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4319	$6.4815 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$2.20/mo premium · $615.00 deductible	4Non-Preferred Drug	29%	29%	$0.4301	$6.4515 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Arizona — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$0.1273	$1.9115 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.70/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1504	$2.2615 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$66.40/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1118	$1.6815 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$97.50/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2666	$4.0015 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$0.1137	$1.7115 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$2.50/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1158	$1.7415 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0939	$1.4115 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$119.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1137	$1.7115 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	32%	32%	$0.5104	$7.6615 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5115	$7.6715 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Nevada — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$52.60/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1091	$1.6415 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$76.70/mo premium · $615.00 deductible	2Generic	$6.00	$18.00	$0.1490	$2.2315 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$95.60/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1164	$1.7515 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.10/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2302	$3.4515 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1095	$1.6415 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$43.70/mo premium · $601.00 deductible	3Preferred Brand	18%	13%	$0.1107	$1.6615 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$97.40/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0823	$1.2315 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$148.70/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1095	$1.6415 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4704	$7.0615 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$2.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4718	$7.0815 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Oregon and Washington — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$0.1177	$1.7715 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$38.40/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1452	$2.1815 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1089	$1.6315 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$110.00/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2254	$3.3815 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0963	$1.4415 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$22.10/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0975	$1.4615 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$85.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0756	$1.1315 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$108.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0963	$1.4415 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.4520	$6.7815 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4533	$6.8015 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Idaho and Utah — 10 plans, 10 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
SilverScript Choice (PDP)$27.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1284	$1.9315 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Extra Rx (PDP)$56.30/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1170	$1.7615 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$56.50/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1469	$2.2015 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$128.60/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1128	$1.6915 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$132.60/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2449	$3.6715 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.0841	$1.2615 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$19.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0861	$1.2915 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$115.50/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0841	$1.2615 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.3304	$4.9615 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$23.70/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.3288	$4.9315 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Maine and New Hampshire — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$0.1146	$1.7215 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$82.40/mo premium · $615.00 deductible	2Generic	$7.00	$21.00	$0.1423	$2.1315 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$104.30/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2177	$3.2715 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1115	$1.6715 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$54.40/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1132	$1.7015 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0867	$1.3015 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$150.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1115	$1.6715 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	27%	27%	$0.4816	$7.2215 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4816	$7.2215 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Virginia — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$39.60/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1572	$2.3615 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.80/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2456	$3.6815 units	Prior authorization Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$133.80/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1180	$1.7715 units	Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	25%	20%	$0.1104	$1.6615 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$0.00/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1128	$1.6915 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$78.20/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0996	$1.4915 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$87.60/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1104	$1.6615 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	31%	31%	$0.4646	$6.9715 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4656	$6.9815 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Alaska — 9 plans, 9 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Assurance Rx (PDP)$0.00/mo premium · $615.00 deductible	2Generic	10%	10%	$0.1525	$2.2915 units	Quantity limit 15 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$53.20/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1602	$2.4015 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$100.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2218	$3.3315 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.00/mo premium · $615.00 deductible	3Preferred Brand	24%	19%	$0.0994	$1.4915 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$10.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.0996	$1.4915 units	Quantity limit 15 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	3Preferred Brand	18%	18%	$0.0576	$0.8615 units	Prior authorization Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$112.40/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.0994	$1.4915 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$0.00/mo premium · $615.00 deductible	4Non-Preferred Drug	28%	28%	$0.5049	$7.5715 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$19.70/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.5073	$7.6115 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Hawaii — 8 plans, 8 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Saver from UHC (PDP)$0.00/mo premium · $615.00 deductible	2Generic	$8.00	$24.00	$0.1687	$2.5315 units	Prior authorization Quantity limit 15 per 30 days
SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible	2Generic	$10.00	$30.00	$0.1694	$2.5415 units	Prior authorization Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible	2Generic	$10.00	$0.00	$0.2812	$4.2215 units	Prior authorization Quantity limit 15 per 30 days
Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible	3Preferred Brand	23%	18%	$0.1168	$1.7515 units	Quantity limit 15 per 30 days
Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible	3Preferred Brand	20%	15%	$0.1174	$1.7615 units	Quantity limit 15 per 30 days
Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible	3Preferred Brand	$45.00	$125.00	$0.1168	$1.7515 units	Quantity limit 15 per 30 days
Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible	4Non-Preferred Drug	40%	40%	$0.4724	$7.0915 units	Quantity limit 15 per 30 days
Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	35%	$0.4724	$7.0915 units	Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Puerto Rico — 3 plans, 3 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
HealthSpring Extra Rx (PDP)$50.00/mo premium · $615.00 deductible	2Generic	$5.00	$3.00	$0.1142	$1.7115 units	Quantity limit 15 per 30 days
HealthSpring Assurance Rx (PDP)$65.70/mo premium · $615.00 deductible	2Generic	$2.00	$2.00	$0.1006	$1.5115 units	Quantity limit 15 per 30 days
AARP Medicare Rx Preferred from UHC (PDP)$145.10/mo premium · $615.00 deductible	2Generic	25%	25%	$0.2845	$4.2715 units	Prior authorization Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

American Samoa — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	2Generic	25%	25%	$0.3098	$4.6515 units	Prior authorization Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Guam — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$0.00/mo premium · $615.00 deductible	2Generic	25%	25%	$0.2996	$4.4915 units	Prior authorization Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Northern Mariana Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$32.10/mo premium · $615.00 deductible	2Generic	25%	25%	$0.3098	$4.6515 units	Prior authorization Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

U.S. Virgin Islands — 1 plan, 1 with restrictions

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
AARP Medicare Rx Preferred from UHC (PDP)$114.80/mo premium · $615.00 deductible	2Generic	25%	25%	$0.2968	$4.4515 units	Prior authorization Quantity limit 15 per 30 days

Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity — elsewhere it depends on what is prescribed.

Coverage by region

Plan-by-plan detail